Week 28

Quiz 28 Context:

A 55-year-old male presents for follow-up after being seen in the emergency room the previous week for minor trauma associated with a motor vehicle accident. He reports that there was mild pain in his hands at the time of the accident, and now the pain has worsened.

Notable medical history includes that the patient suffers from chronic kidney disease thought to result from hypertension, with a creatinine of 3.4 mg/dL baseline. He also reports a history of unspecified arthritis, hypertension, hyperlipidemia, and asthma/COPD.

Physical examination reveals a male patient in no distress. Vital signs reveal a temperature of 37.4 degrees Celsius, heart rate 90 bpm, blood pressure 156/90 mmHg. The exam is most notable for asymmetric polyarticular involvement of the joints of the hands and feet. Involved joints are tender, warm and swollen. There is no rash.

As part of the evaluation, a plain film of the hands and feet is obtained.
The key findings of the study are shown above.

This patient presents with asymmetric painful swollen hands and evidence on imaging studies of tophi surrounding the involved joints. There is evidence of relative preservation of the joint spaces as well as occasional "punched out" erosions of bone with sclerotic borders. These findings are most consistent with chronic gout, likely the etiology of his previous arthritis.
You have correctly identified this week's Image of the Week. Now test your knowledge of other aspects of gout. Do you knowâ€¦
â€¦the usual timing of the first attack of gout in a patient with asymptomatic hyperuricemia? At what age does the first attack usually occur in males and in females? What are the most commonly involved joints? Does this pattern change as time progresses and patients age?
â€¦the best approach to confirm the diagnosis of gout? What is the relationship between serum urate levels and the diagnosis of gout? What is the method for evaluation of urate crystals by microscopy, and what is the typical size, shape, brightness, and appearance of these crystals? How does the urate crystal appear under a polarizing microscope, and how does this help in the differential diagnosis of a crystal arthropathy? What should one look for in the situation in which a polarizing microscope is not available?
â€¦ the recommendations for the treatment of an acute gout attack, as well as for prophylaxis, in patients with chronic kidney disease such as the one in the case above? What drugs should be avoided, and why? Which agents can be used? Do these recommendations differ in the renal transplant population?
The answers to these questions, and a concise review of the pathogenesis, diagnosis, and treatment of the complications of gout, can be found here within the Cleveland Clinic Foundation Disease Management Project.

This history, examination, and data are most consistent with which of the following possibilities as a cause for the symptoms: